Abstract

Background

Implementation research is concerned with bridging the gap between evidence and practice
through the study of methods to promote the uptake of research into routine practice.
Good quality evidence has been summarised into guideline recommendations to show that
peri-operative fasting times could be considerably shorter than patients currently
experience. The objective of this trial was to evaluate the effectiveness of three
strategies for the implementation of recommendations about peri-operative fasting.

Methods

A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted
during 2006 to 2009 with a national sample of UK hospitals using time series with
mixed methods process evaluation and cost analysis. Hospitals were randomised to one
of three interventions: standard dissemination (SD) of a guideline package, SD plus
a web-based resource championed by an opinion leader, and SD plus plan-do-study-act
(PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia.
Secondary outcomes included duration of food fast, patients’ experiences, and stakeholders’
experiences of implementation, including influences. ANOVA was used to test differences
over time and interventions.

Results

Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting
observations were recorded. No significant effect of the interventions was observed
for either fluid or food fasting times. The effect size was 0.33 for the web-based
intervention compared to SD alone for the change in fluid fasting and was 0.12 for
PDSA compared to SD alone. The process evaluation showed different types of impact,
including changes to practices, policies, and attitudes. A rich picture of the implementation
challenges emerged, including inter-professional tensions and a lack of clarity for
decision-making authority and responsibility.

Conclusions

This was a large, complex study and one of the first national randomised controlled
trials conducted within acute care in implementation research. The evidence base for
fasting practice was accepted by those participating in this study and the messages
from it simple; however, implementation and practical challenges influenced the interventions’
impact. A set of conditions for implementation emerges from the findings of this study,
which are presented as theoretically transferable propositions that have international
relevance.